The Longitudinal Communication Curriculum at Leipzig University, Medical Faculty – implementation and first experiences

Purpose: Communication skills are an essential instrument for building a sustainable patient-doctor-relationship for future doctors. They are learnable and teachable. The learning should be facilitated with the help of a longitudinal curriculum, which is planned at Leipzig University. Project: At the Medical Faculty of Leipzig University, the Longitudinal Communication Curriculum is established since 2016/17. Up to now, the curriculum consists of four parts in which students repeatedly practise their communication skills in curricular and extracurricular courses. Several formats help to teach an integrated learning of communication and physical examination skills. Assessment of communication skills is also performed. Curricular implementation is accompanied by concomitant evaluation. Results: Three parts of the curriculum already have taken place. Students report an increase in communication skills. Students rate the units as instructive and helpful. The assessment of communication skills occurs in two clinical practical examinations (OSCEs). Together with summative assessment a formative feedback was implemented. Students judge this practice as highly positive. Discussion: The curriculum is part of undergraduate medical education in Leipzig. It would be beneficial to add another simulated patient encounter, as well as interprofessional units. Student questionnaires will be evaluated and results will help to develop the curriculum. Conclusion: Consolidation of the curriculum accompanied by evaluation and adaption of content can help to assure the quality of the curriculum. Additional professions and study units shall be integrated in the Longitudinal Communication Curriculum in the future.


Project
The longitudinal communication curriculum was developed by a project group of preclinical (medical psychology and medical sociology) and clinical colleagues (ophthalmology, internal medicine, anaesthesiology, otolaryngology and child psychiatry), as well as medical students. The director of the Department of Paediatric Psychiatry, Psychotherapy and Psychosomatics at University of Leipzig Medical Centre and the medical director of the Skills and Simulation Centre LernKlinik Leipzig lead the group. The curriculum starts in the 3 rd /4 th semesters and continues throughout the entire undergraduate medical education. Communication skills are taught repeatedly. During the different parts of the Longitudinal Communication Curriculum various learning objectives are in focus. The roles Communicator and Team Manager of CanMEDs [9] serve as starting point. For implementation, learning objectives out of the existing curriculum of these courses were chosen: topics that require clinical practical skills, topics that include or have clinical practice planned and topics that are interdisciplinary. The aim is an integration of the existing curriculum into the reformed course of studies with a longitudinal, interdisciplinary teaching of communication and social skills (for the curriculum see figure 1). For fostering curricular implementation a centrally coordinated SP programme is established. The implementation of the Longitudinal Communication Curriculum and the SP programme is funded by the Saxon State Ministry for Science, Culture and Tourism (SMWK) since winter semester 2016/17. The Longitudinal Communication Curriculum as well as the SP programme are meanwhile part of the curriculum in Leipzig. It is described in the following.

Part I: 2 nd year of medical studies
The Longitudinal Communication Curriculum starts in the second academic year within the communication course of the division of medical psychology and medical sociology, which is based on the COMSKIL model (COMSKIL, [15]). Basic communication content is taught in the course. In addition to imparting communication content over two semesters, the students practice building up a patient-doctor relationship in SP encounters. Groups of 10 students each experience 11 different SP encounters. Courses are moderated by faculty members of the Division of Medical Psychology and Medical Sociology as well as by peer-student tutors from the LernKlinik Leipzig who are didactically and professionally trained. One communication unit including preparation and feedback lasts 50 minutes. The topics are thematically connected to clinical scenarios (see figure 2). These examples are edited in a way students themselves can prepare for the course. The topics furthermore are part of the communication course itself. Basic knowledge is imparted to students prior to the SP encounters in order to be able to deal with different situations. Every student is involved in a SP encounter and receives feedback from this SP, the participating peers and the moderating faculty or peer-student tutors. During the other SP encounters the students have the possibility of participating while observing their peers. At the end, they give a structured feedback to their peers.

Part II: 3 rd year of medical studies
The so-called Clinical Skills Course takes place in the 5 th semester where students learn physical examination techniques. Additionally, basic skills in communication are repeated and complemented. This takes place in two lectures focusing on patient-doctor communication in internal medicine. Accompanying these two lectures stu-

Part III: 4 th year of medical studies
Lacking communication skills, rather than medical skills, can lead to false decisions especially in critical situations [16]. This should be taken into account and trained throughout the medical curriculum, particularly in cooperation with interprofessional teams. In Leipzig, the theoretical background for team communication and teamwork is based on the framework of crisis resource management (CRM, [16]

Part IV: 5 th year of medical studies
So far, the final unit of the curriculum planned will be integrated into the PBL course on medicine of the elderly in the 10 th semester, prior to the final year in medicine comprising the hospital clerkship. The aim is to primarily introduce the topic of behavioral change with techniques of Motivational Interviewing (MI) [17]. For this purpose, a 45-minute lecture is planned, starting in the summer term of 2020. Students can work on a PBL case dealing with behavioural change. SP encounters involving MI are to take place in a pilot phase. In these the learned knowledge can be put into practice. The Berlin global rating scale (BGR) is used as framework for evaluating patient-doctor encounters [18], [19]. This scale was selected due to its simple structure and easy applicability.

SP programme
Students are introduced to the BGR during COMSKIL courses in their second year of medical education. They get to know the BGR as a global instrument for evaluating patient-doctor encounters by focusing on four dimensions: empathy, structural, verbal and nonverbal expression. In the Longitudinal Communication Curriculum, the BGR is used for self-and peer-assessment. Accordingly, the scale is also used as the basis for communication skills assessment in the OSCE. Through continuous use, students have the opportunity to appreciate this scale as a global instrument for evaluation and improvement of their communication skills.

Feedback as recurrent element throughout the curriculum
Feedback is used for giving students a structured and immediate response to their ongoing learning [4], [5], [6], [20] After every SP encounter, feedback on communication skills is given. Furthermore, students themselves practise giving feedback. Every SP encounter is followed by a SP feedback, a peer feedback and a feedback from faculty. During the OSCE, feedback is also provided. In both OSCEs, after the 5 th and 7 th semester respectively, students receive feedback from their examiner after each station within the OSCE. At stations with SP involvement, students also receive a formalized and structured SP feedback. Students receive feedback on (team) communication as well as clinical skills. Examiners are trained to give structured feedback. This feedback gives the students the opportunity to learn which specific clinical or communication skills they need to work on. BGR and feedback are recurrent themes throughout the entire curriculum. In figure 3, the learning objectives of the complete Longitudinal Communication Curriculum are summarized.

Results
The implementation of the curriculum is continuously evaluated. Students answer mainly paper-based questions (to increase the return rate). Questionnaires are distributed via EvaSys ® (Evasys GmbH, 2017-2019, Lüneburg). The first cohort will have completed the curriculum by the end of summer term 2020. Students are all asked to take part in five questionnaire-based assessments over time (T1-T5). Data have been collected up to the 4 th cohort (see figure 4). Data on attitude towards communication are collected via the Communication Skills Attitude Scale [21], the relevance of empathy in the patient-doctor-relationship via the Jefferson Scale of Physician Empathy, student version [22], and data on personal communication skills are recorded via an adaptation of the BGR [18], [19]. Furthermore, students rate which changes in communication skills they observe on themselves. The learning situations of the Longitudinal Communication Curriculum are evaluated by the students as well (Likert scales). We report the results of students' evaluation on the first three assessment points of the curriculum for cohorts 1 and 2 as well as the 4 th assessment point for cohort 1. Data were analyzed using IBM ® SPSS ® Statistics Version 24.

Ethics approval and participation consent
Students were informed about the study. Written consent was obtained at the 1 st assessment point (T1). At every further assessment point students were informed that their data are part of a study. Data were collected anonymously. This study received an approval of the ethics committee of the Medical Faculty, University of Leipzig (149/17 -ek).

Curriculum evaluation by cohorts one and two
After each course unit, students evaluated the respective course and the overall Longitudinal Communication Curriculum.
At the 2 nd assessment point (T2) we obtained data from n=445 students (mean=22 years, 67% women, 33% men). At the 3 rd assessment point (T3), data of n=385-548 students are available (several questions were only partly answered, mean age=23 years, 66% women, 34% men). From the 4 th assessment point (T4), data of n=72 students of the first cohort are available (mean age=24 years, 65% women, 35% men). When comparing data from cohort 1 and 2, no differences can be seen concerning self-assessed communication skills, age or gender. Students of both cohorts had a SP encounter between T1 an T2. The Clinical Skills Course, SP encounter in ophthalmology and video analyses in internal medicine took place between T2 and T3. In T2, students report an improvement in communication skills and experience SPs as helpful for development of communication skills (see figure 5).
After the Clinical Skills Course (T3) in the 5 th semester, both video analysis and SP encounter were regarded as a valuable combination of learning the use of communication skills and clinical examination skills (see figure 6).
Receiving feedback from SPs during OSCE assessments is also considered as useful (see figure 7).
When looking at open-ended questions, students report a heterogenic feedback quality. At T4, 60% of cohort 1 felt more confident in team communication, registering an improvement in personal team communication competence. About 10% report a strong improvement (see figure 8).

Discussion
After implementation of the Longitudinal Communication Curriculum, medical students at Leipzig University report an increase in communication skills after SP encounters. The combination of teaching communication and clinical examination skills in the Clinical Skills Course was judged as helpful; students feel that they benefit from the PBL courses on team communication. How self-rated communication skills develop over time will be investigated further on. These future results will be imminent for curricular adaptations. Communication skills are assessed in years 3 and 4 in one OSCE station, respectively. It remains to be discussed     if communication skills should be assessed in one way or another at each OSCE station in future, as is already the case in Basel [13]. We focused on the implementation of basic communication skills as well as team communication skills. To better acknowledge the role of "team manager" (CanMEDS, [9]) in the future, inter-and intraprofessional scenarios should be added. First experiences with an interprofessional elective course for students of the 9 th semester and midwifery students seem promising. At the same time, such projects are associated with high personnel costs and are difficult to integrate into the existing medical curriculum.